A nurse is assessing a pregnant client diagnosed with HELLP syndrome. Which of the following findings is most concerning?
Blood pressure of 140/90 mmHg
Platelets 250,000/mm3
Right upper quadrant pain
Fetus expected weight for gestation
The Correct Answer is C
A. Blood pressure of 140/90 mmHg: While elevated, this blood pressure reading is at the threshold of hypertension and is common in HELLP syndrome. It is not the most alarming finding unless it continues to rise or is accompanied by signs of end-organ damage.
B. Platelets 250,000/mm³: This is within the normal range and does not reflect thrombocytopenia, which is a hallmark of HELLP syndrome. A concerning platelet count would be below 100,000/mm³, suggesting a risk for bleeding complications.
C. Right upper quadrant pain: This symptom may indicate liver involvement, such as hepatic swelling or rupture, and is a serious sign in HELLP syndrome. It can signal worsening disease and the need for immediate evaluation and possible intervention.
D. Fetus expected weight for gestation: A fetus growing appropriately is a reassuring sign in pregnancy. HELLP syndrome can lead to fetal growth restriction, but expected weight indicates adequate placental function at the moment and is not an urgent concern.
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Related Questions
Correct Answer is D
Explanation
A. Station of the presenting part: Station refers to the position of the fetal presenting part in relation to the maternal ischial spines. While it can indicate fetal descent, it does not confirm the presence of active labor and may not change significantly early in the process.
B. Pattern of contractions: Contractions in true labor are typically regular and increase in intensity, but alone, they do not confirm true labor. False labor can also involve contractions that mimic this pattern, making them less reliable as the sole indicator.
C. Rupture of the membranes: Rupture of membranes can occur before true labor begins or even without labor. While it often precedes delivery, it is not definitive evidence that labor is active, especially if no cervical change is observed.
D. Changes in the cervix: Effacement and dilation of the cervix are the hallmark signs of true labor. These changes confirm that uterine contractions are causing physiological progress toward delivery, distinguishing true labor from false labor.
Correct Answer is A
Explanation
A. Respiratory rate of 8 breaths per minute: A respiratory rate below 12 breaths per minute is a sign of magnesium toxicity. Magnesium sulfate can depress the central nervous system, and a rate of 8 indicates potential respiratory compromise, requiring immediate intervention and possible discontinuation of the infusion.
B. Urine output of 60 mL in the past two hours: Although slightly low, this output is not yet at the critical level of concern. Urine output should be ≥30 mL/hr to ensure magnesium is excreted effectively. Continued monitoring is needed, but it does not require immediate action.
C. Deep tendon reflexes of +2: A +2 reflex is considered normal and indicates that the client is not currently experiencing neuromuscular depression. Loss or absence of reflexes would be more concerning for magnesium toxicity.
D. Complaints of mild nausea and flushing: These are common and expected side effects of magnesium sulfate therapy. While they should be documented and monitored, they do not suggest toxicity and do not require urgent intervention.
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